Sparing the Aortic Root

[ETC908]

I'm 42 and have a bicuspid aortic valve and aneurysm of the ascending aorta, severe stenosis and AR (although asymptomatic). I'm scheduled for surgery in 3 weeks...mechanical On-X valve, Dacron graft repairing the ascending aorta. I just found out that my surgeon is planning on sparing the aortic root, stating that it's normal. He is of course amenable to calling an audible in the OR and replacing the root if he sees something that differs from the CT angiogram, but seemed doubtful that he'd have to.
I understand that this decreases the complexity of the surgery as the coronaries don't need to be reattached. Are there any downsides that folks know of to sparing the aortic root (ie odds of it developing an aneurysm later in life)? I appreciate any insight or experiences that folks have had. Thank you.

 

[Critter]

Same thing happened to me. My surgeon spared the root. I was at 4.3 cm and he said he would have put a piece of Dacron if it was 4.5 cm. He tightened up the root using suture and the valve is seated perfectly. I have not experienced any downside . My chest pain went away right after surgery.

 

[ETC908]

Thank you. Very glad to hear that you are doing well. I still have to ask my surgeon this (I continue to think of additional questions after each conversation)...but did your surgeon give you any indication on the likelihood of developing an aneurysm of the root later on in life?

 

[MdaPA]

Are there any downsides that folks know of to sparing the aortic root (ie odds of it developing an aneurysm later in life)?

Did you see these?

Outcome of reoperative aortic root or ascending aorta replacement after prior aortic valve replacement - Dun - Journal of Thoracic Disease

Bicuspid Aortic Valve with Aneurysm: Guidance for Tailoring Surgical Strategy

The development of ascending aortic aneurysms after elective aortic valve replacement with St Jude mechanical valve prosthesis in the bicuspid patient: a pilot study - PubMed

 

[Critter]

It’s one of those things when they got you opened up making a decision at that time. I was told my prognosis is excellent according to surgeon and cardiologist. I don’t plan on doing any heavy weight lifting and I’m enjoying my new found joy in jogging for aerobic health. Never been able to do that. Gives me a euphoric feeling afterwards. Don’t want to do anything that increases my intra-thoracic pressure and mess my valve up or stress Aortic root. There is always a possibility of something happening but I trust the judgment of my physicians and I have no concerns. I had an echo 30 days after replacement and my trans-aortic gradient dropped from 80s to low 20s mm. 20 is normal pressure across the valve, so the tubing is under much less pressure so I infer a decrease in chance of aneurysmal dilation and rupture unless I have some weird connective tissue disorder like Marfan’s syndrome. I don’t think I have that.

 

[pellicle]

it was my understanding that root sparing with mechanical valve and aortic graft on the aneurysm were mutually exclusive. I could be wrong
https://sydneyheartandlung.com.au/surgery/aortic-surgery/aortic-valve-replacement/

The aortic root is the section of the aorta (the large artery leaving the heart) that is attached to the heart. The aortic root includes the annulus (tough, fibrous ring); the leaflets of the aortic valve; and the openings where the coronary arteries attach (coronary ostia). ​

In my case the graft and mechanical aortic valve were sewn onto the heart and onto the remainder of the aorta just around the arch. Using a pre-attached graft saved time on the pump.

Personally I'd be inclined to leave as few old parts as possible lying around. Like when changing a cam belt, one usually changes the water pump too.

 

[drleng]

This is a technical question that only an experienced competent cardiothoracic surgeon can answer well because it really is based on the individual and your haemodynamics etc. Either trust your surgeon to make the right decision or get a 2nd surgical opinion if in doubt (always).

 

[AZ Don]

I had a valve sparing procedure done for an aneurysm of the root and ascending aorta. The Dr actually spared one side of my root, sparing my coronary artery. I've worried that I could get an aneurysm in the remaining part of the root but 8 years now and it's still doing fine.

 

[tom in MO]

it was my understanding that root sparing with mechanical valve and aortic graft on the aneurysm were mutually exclusive. I could be wrong
https://sydneyheartandlung.com.au/surgery/aortic-surgery/aortic-valve-replacement/

The aortic root is the section of the aorta (the large artery leaving the heart) that is attached to the heart. The aortic root includes the annulus (tough, fibrous ring); the leaflets of the aortic valve; and the openings where the coronary arteries attach (coronary ostia). ​

In my case the graft and mechanical aortic valve were sewn onto the heart and onto the remainder of the aorta just around the arch. Using a pre-attached graft saved time on the pump.

Personally I'd be inclined to leave as few old parts as possible lying around. Like when changing a cam belt, one usually changes the water pump too.

Humans are not cars.

I agree with drleng This is a technical question that only an experienced competent cardiothoracic surgeon can answer well because it really is based on the individual and your haemodynamics etc. I trusted my surgeon to make the right decisions before operation and in-theater.

 

[ETC908]

Thank you all for the responses and references. I agree, I think this is a question better left to the Cardiothoracic surgeons, but was curious about the experiences of others. I had a surgeon recommend the Ross, and he was going to replace the root along with the ascending aorta. I didn't question him about the root because I was more fixated on questions regarding the Ross (in hindsight I'm guessing maybe the root would need to be replaced in order to accommodate the Ross procedure in conjunction with aneurysm repair?)
The surgeon placing the mechanical valve said he wouldn't replace the root because it's normal. I don't have any qualms about it as it seems more technically involved, more time on bypass, etc, to detach/reattach the coronaries, but I will ask him about long-term risks. I don't have Marfan's or connective tissue disease. I may be wrong, but it seems to me that it's still debated whether it's a high-flow issue that causes aneurysms with bicuspid valves, or whether it's a connective tissue issue. If it's the former, then I don't see any reason why a subsequent aneurysm of the root would develop once the underlying issue gets fixed. Can't seem to find good info on long-term prognosis of the root either way, but am waiting to hear back from my docs.

 

[ETC908]

Did a deeper dive, and found some additional info. Obviously still limited info:
https://pubmed.ncbi.nlm.nih.gov/25750009/https://pubmed.ncbi.nlm.nih.gov/29656818/

 

[cldlhd]

I'm 42 and have a bicuspid aortic valve and aneurysm of the ascending aorta, severe stenosis and AR (although asymptomatic). I'm scheduled for surgery in 3 weeks...mechanical On-X valve, Dacron graft repairing the ascending aorta. I just found out that my surgeon is planning on sparing the aortic root, stating that it's normal. He is of course amenable to calling an audible in the OR and replacing the root if he sees something that differs from the CT angiogram, but seemed doubtful that he'd have to.
I understand that this decreases the complexity of the surgery as the coronaries don't need to be reattached. Are there any downsides that folks know of to sparing the aortic root (ie odds of it developing an aneurysm later in life)? I appreciate any insight or experiences that folks have had. Thank you.

As pretty much everyone out here I'm not a medical expert but this doesn't sound right to me. If you're getting a brand new mechanical valve and having your aneurysm replaced with a graph I have no idea why they're root when it be replaced along with it? Six years ago I had my barely leaking BAV repaired while they were in there replacing my aneurysm and root with a dacron graft. From a lot of the information I read and the advice from My surgeon the new brute would help to stabilize the valve and keep it in the ideal ( or at least as close to that as they could get) geometry. Now that doesn't apply to you because you're getting a mechanical valve but my point of including that is even when keeping the native valve and having it repaired if you're having your ascending aneurysm replace with a graft It's common to replace the root as well. But with a mechanical valve I think it comes all in one unit: the valve, the root, and the ascending graft.

 

[cldlhd]

I'm 42 and have a bicuspid aortic valve and aneurysm of the ascending aorta, severe stenosis and AR (although asymptomatic). I'm scheduled for surgery in 3 weeks...mechanical On-X valve, Dacron graft repairing the ascending aorta. I just found out that my surgeon is planning on sparing the aortic root, stating that it's normal. He is of course amenable to calling an audible in the OR and replacing the root if he sees something that differs from the CT angiogram, but seemed doubtful that he'd have to.
I understand that this decreases the complexity of the surgery as the coronaries don't need to be reattached. Are there any downsides that folks know of to sparing the aortic root (ie odds of it developing an aneurysm later in life)? I appreciate any insight or experiences that folks have had. Thank you.

Just to add something I didn't include I could understand how it makes the surgery a little more simple but that's the reason why you have a high quality surgeon. I mean all else being equal the shorter and less complicated the surgery the better but if you have an ascending aneurysm I would have to imagine the odds of your root becoming aneurysmal would be relatively high. I would rather have it done while in there. It still doesn't seem nearly as complicated as what I had done- the David V valve sparing procedure where they have to repair, or try to repair, a leak in the valve then fit the right size root for the native valve which I would imagine is more difficult than one fitted from the factory to a mechanical and then they have to sew it all together and then attach the coronary arteries as well.

 

[cldlhd]

it was my understanding that root sparing with mechanical valve and aortic graft on the aneurysm were mutually exclusive. I could be wrong
https://sydneyheartandlung.com.au/surgery/aortic-surgery/aortic-valve-replacement/

The aortic root is the section of the aorta (the large artery leaving the heart) that is attached to the heart. The aortic root includes the annulus (tough, fibrous ring); the leaflets of the aortic valve; and the openings where the coronary arteries attach (coronary ostia). ​

In my case the graft and mechanical aortic valve were sewn onto the heart and onto the remainder of the aorta just around the arch. Using a pre-attached graft saved time on the pump.

Personally I'd be inclined to leave as few old parts as possible lying around. Like when changing a cam belt, one usually changes the water pump too.

Hey it's funny you said that. When I had a console with my surgeon prior to surgery I told him I wanted him to do everything that he thought might need done down the road while he had the wheels off..... He seemed to get a chuckle out of that

 

[cldlhd]

Humans are not cars.

I agree with drleng This is a technical question that only an experienced competent cardiothoracic surgeon can answer well because it really is based on the individual and your haemodynamics etc. I trusted my surgeon to make the right decisions before operation and in-theater.

It is true that we are not cars but some analogies do hold true to an extent. I often wondered around the time of my surgery about the whole removing the car and every buttons and reattaching them. I know that it's not like a illustration of a surgery where everything's nice and neat, I'm sure there's scar tissue and such. But the analogy to a car does hold true in my mind insofar as to these surgeons opening you up and putting you back together is really not much more of a big deal to them than a mechanic changing some spark plugs. It's what they do every day and they don't look at it like a big deal. That doesn't mean they don't care but if they sat and thought about what the surgery meant to the person being operated on and their families it would be difficult for them to do their jobs.

 

[cldlhd]

Thank you all for the responses and references. I agree, I think this is a question better left to the Cardiothoracic surgeons, but was curious about the experiences of others. I had a surgeon recommend the Ross, and he was going to replace the root along with the ascending aorta. I didn't question him about the root because I was more fixated on questions regarding the Ross (in hindsight I'm guessing maybe the root would need to be replaced in order to accommodate the Ross procedure in conjunction with aneurysm repair?)
The surgeon placing the mechanical valve said he wouldn't replace the root because it's normal. I don't have any qualms about it as it seems more technically involved, more time on bypass, etc, to detach/reattach the coronaries, but I will ask him about long-term risks. I don't have Marfan's or connective tissue disease. I may be wrong, but it seems to me that it's still debated whether it's a high-flow issue that causes aneurysms with bicuspid valves, or whether it's a connective tissue issue. If it's the former, then I don't see any reason why a subsequent aneurysm of the root would develop once the underlying issue gets fixed. Can't seem to find good info on long-term prognosis of the root either way, but am waiting to hear back from my docs.

I'm not sure but I believe having a BAV is considered a connective tissue disorder especially if you have an aneurysm. Also there is a lot of thought now that the aneurysm is caused more by the genes that gave you the BAV rather than the hemodynamics

 

[ETC908]

Thanks for the thoughts. I will talk with the surgeon again. His sentiment was that the root was normal, and if we could avoid having to re-perfuse the coronaries then that would be ideal. He did not think a reoperation in my future was a very likely outcome. He was willing to call an audible intraoperatively and take care fo the root if for some reason it didn't look as good as the CT showed, but he thought that was unlikely to happen.
Again, that's just one opinion but he's been at this for years and does at least a hundred of these a year. I've spoken to other surgeons and anesthesiologists who work with him and patients who have had him, and all of the feedback has been glowing. So I have to trust his expertise and experience. Based on my limited knowledge, I think this fits into realm of not one size fits all. I share the concerns about the root potentially developing an aneurysm later on. I shared a couple of articles above that suggest that that may not be a concern, and outcomes are still good. Seems like it's still debated whether it's a hemodynamic issue or a connective tissue issue that causes these aneurysms.
On the flip side, I do feel that the less intervention the better as having to operate on the coronaries introduces other variables and areas for complications. There have been other people on this forum who had the ascending aorta and valve replaced while sparing the root, and they seem to be doing ok. Between that, and the articles I shared, I don't think it's unreasonable or unheard of to do that. I checked with my cardiologist as well, who felt that it was appropriate. I will talk to the surgeon one last time to get his final thoughts on it, but I think I'm comfortable proceeding as planned.

 

[Brinntache]

As someone who ended up back in hospital with complications, anything that reduces the potential for complications is good. And if it doesn't lead to future operations, it's gold. Best of luck.

 

[cldlhd]

Thanks for the thoughts. I will talk with the surgeon again. His sentiment was that the root was normal, and if we could avoid having to re-perfuse the coronaries then that would be ideal. He did not think a reoperation in my future was a very likely outcome. He was willing to call an audible intraoperatively and take care fo the root if for some reason it didn't look as good as the CT showed, but he thought that was unlikely to happen.
Again, that's just one opinion but he's been at this for years and does at least a hundred of these a year. I've spoken to other surgeons and anesthesiologists who work with him and patients who have had him, and all of the feedback has been glowing. So I have to trust his expertise and experience. Based on my limited knowledge, I think this fits into realm of not one size fits all. I share the concerns about the root potentially developing an aneurysm later on. I shared a couple of articles above that suggest that that may not be a concern, and outcomes are still good. Seems like it's still debated whether it's a hemodynamic issue or a connective tissue issue that causes these aneurysms.
On the flip side, I do feel that the less intervention the better as having to operate on the coronaries introduces other variables and areas for complications. There have been other people on this forum who had the ascending aorta and valve replaced while sparing the root, and they seem to be doing ok. Between that, and the articles I shared, I don't think it's unreasonable or unheard of to do that. I checked with my cardiologist as well, who felt that it was appropriate. I will talk to the surgeon one last time to get his final thoughts on it, but I think I'm comfortable proceeding as planned.

If you don't mind me asking who is the surgeon? If you don't want to share the information I understand and I'm not questioning his abilities I was just curious. Obviously he has more knowledge about it than we do out here but I guess when you come out here we're all you got to pick from.....lol.
That's the whole thing-the unknowns. You could spare the route and then 5 to 10 years from now you're back in there to have it replaced and obviously you would regret that choice. Or you could get the root replaced and the more complicated surgery could cause an issue, although if he does as many a year as you say I doubt it would. I think my surgeon, Dr Bavaria from Penn, was it been overconfident probably but he made it all sound like changing a light bulb..... Then if you have an issue from the more complicated surgery you would regret that choice because you would never know if replacing the root was something that was necessary. The other possibility is you have the root replaced and the operation goes fine and everything's great for the rest of your life but you would still never know if you needed it done. The unfortunate thing is it is a difficult choice but maybe it's a little helpful to know that there are many of us out here who have had to make a similar choice. Also whichever route you go is certainly better than doing nothing or not having caught it in time so. Best wishes and keep us updated if you don't mind

 

[pellicle]

As someone who ended up back in hospital with complications,

boy do I know that story.